Americans are living longer than ever. A periodic chartbook published by the Federal Interagency Forum on Aging-Related Statistics predicted that the eldest U.S. residents—individuals ages 85 and older—would be the most rapidly growing age group in this nation. This population numbered 3 million in 1994, just more than 1 percent of the population. Today, this group numbers 6.7 million. By 2050, 19 million U.S. residents are expected to fall into this category.*
Oral anticoagulants are one of the most frequently prescribed medications in the elderly. The most common indications for the use of anticoagulants are atrial fibrillation (AF), valvular heart disease, and venous thromboembolic disease. Indeed, the prevalence of AF increases significantly with age. Data from the anticoagulation and risk factors in atrial fibrillation (ATRIA) study have shown that 9 percent of patients ages 80 years or older have AF. Only about 15 percent of all strokes in the U.S. were attributed to AF, but these numbers increase to 36 percent in patients who are older than age 80.†
One of the challenges we face as health care providers is weighing the benefits of anticoagulation therapy against the risks associated with falls. It is evident that elderly patients who would benefit the most from anticoagulation also are at the highest risk for falls.
One study showed an unadjusted annualized hospitalization rate of 0.47 percent among anticoagulated patients with AF. The study identified 72 intracranial and 98 major extracranial hemorrhages occurring in more than 15,300 people per year among coumadin users. What is more striking, perhaps, is the fact that 76 percent of patients with intracranial hemorrhage had severe disability or died as a result. Of these patients, 71 percent had intracerebral hemorrhage. Among the survivors, 61 percent had major functional disability. Of those patients who survived to be discharged, seven died within 30 days.‡
To examine the occurrence of patients ages 80 or older on anticoagulants in the National Trauma Data Bank® (NTDB®) research admission year 2017, medical records were searched using the International Classification of Diseases, Tenth Revision Clinical Modification codes. Specifically searched were records for patients ages 80 and older and records containing a comorbid conditions field entry of 31 (anticoagulant therapy). A total of 36,033 records were found; 32,847 records contained a discharge status, including 10,208 patients discharged to home, 6,245 to acute care/rehab, 13,070 were sent to skilled nursing facilities, 1,119 were discharged to hospice; 2,205 died (see Figure 1). Of these patients, 59 percent were women; they were on average 86.7 years of age; had an average hospital length of stay of 5.6 days, an intensive care unit length of stay of 4.1 days, an average injury severity score of 9.2; and were on the ventilator for an average of 4.8 days. The most common mechanism of injury (greater than 91 percent) in this group was as a result of falls.
Figure 1. Hospital discharge status
As the U.S. population continues to become older with an associated increase in the incidence of irregular heart rhythms treated with blood thinners, a simple fall may result in life-threatening injuries.
Throughout the year, we highlight these data through brief reports that are published monthly in the Bulletin. The NTDB Annual Report can be found on the American College of Surgeons website as a PDF file at facs.org/ntdb. In addition, information is available on our website about how to obtain NTDB data for more detailed study. If you are interested in submitting your trauma center’s data, contact Melanie L. Neal, Manager, NTDB, at firstname.lastname@example.org.
Statistical support for this column was provided by Ryan Murphy, Data Analyst, NTDB.
*Federal Interagency Forum on Aging-Related Statistics. Older Americans 2016: Key indicators of well-being. Available at: https://agingstats.gov/docs/LatestReport/Older-Americans-2016-Key-Indicators-of-WellBeing.pdf. Accessed January 27, 2019.
†Go AS, Hylek EM, Phillips KA, et al. Prevalence of diagnosed atrial fibrillation in adults: National implications for rhythm management and stroke prevention: The anticoagulation and risk factors in atrial fibrillation (ATRIA) study. J Am Med Assoc. 2001;285(18):2370-2375.